Electronic Medical Records (EMRs) and e prescribing Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical...

Electronic Medical Records (EMRs)and e prescribing

Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical Administration)

Session outcomes

• Benefits and functions of EMRs• Criteria for selecting and implementing an

office EMR• ePrescribing: Standalone or Ambulatory

EMR

EMR vs EHR vs CCR

• EMR: electronic medical record– An electronic medical record for a patient at a particular

site, providing such functionalities as e-prescribing, order/results management, work-flow tasking, communication and messaging

– An EMR is NOT a paper record made electronic

• EHR: electronic health record– The sum of a patient’s EMRs and other health- related

information from multiple sites

• CCR: Continuity of Care Record– Electronic core data set about a patient’s health-

care status and treatment, current and historical

What is Pushing You toward EMRs?

• Patient safety?• Quality improvement?• Rising healthcare costs? • Competitiveness?• Consumer-driven care (participatory health)?

– Internet resources– Personal health records

• Evolution not only toward electronic medical record but also to computer-guided and -supported healthcare

What Can You Gain from EMRs?

• More timely, accurate, complete patient information– No longer practicing blindly– Point of care access to,

capture of, transmission of patient information

– Real-time, remote access

• Improved patient care• Improved patient

safety• Improved outcomes

• Reduced costs of healthcare– Reduced wasteful

duplication– Improved efficiency– Financial squeeze on

physicians

• Reduced hassles• Improved quality of

life– For yourselves– For patients

Critical Success Factors

• Office workflow: Who does what, how, when, where, why?

• Current practice management system?• Information capture preferences?• Staffing: Adequate? Ready?• Colleagues: Supportive? Ready?• Financial planning and expectations– Benefits: Hard, Soft, Stretch

• Realistic timeline• What do you want/need from an EMR?• What features do you want?• What barriers do you face?

Increased revenues• Improved reimbursement• Increased patient volume• Increased charge capture• Decreased accounts receivable

days• Increased net collection rate• Decreased denied claims• Improved E&M compliance• New business opportunities,

clinical trials, data• Improved competitiveness

Improved quality of careImproved patient

satisfaction

Decreased costs• Reduced chart filing costs• Reduced transcription costs• Decreased telephone calls,

faxes from pharmacy• Increased efficiencies,

decreased hassles

Improved quality of life• Improved provider satisfaction• Improved staff satisfaction• Less time after hours

What Outcomes Are You Seeking?

What Features Do You Want?• Clinical

documentation– Options– Management– Scanning– CCR

• Clinical and administrative workflow tasking

• ePrescribing– Drug interaction– Formulary mgmt– Refills

• Referrals• Order entry• Results management– Abnormals– Trends/graphs

• Summary lists– Problems– Allergies– Medications

• Health maintenance reminders

What Features Do You Want?• Charge capture &

coding– Medical necessity– Automated coding– E&M coding &

compliance

• Decision support• Clinical practice

guidelines

• Practice messaging– Internal– External

• Population/disease management

• Patient portals• Patient data entry• Participatory health

What Barriers Do You Face?

• Expense• Selection difficulties• Staff resistance• Time & effort required• Incompatibility of

hardware/software• Ease of use• Security• Lack of technical

expertise

• Obsolescence• Ease of integration• Concerns about ROI• Solutions not right for

you• Lack of demonstration

site• Data/chart conversion• Increase documentation• Other?

What Do You Want to Achieve?

When you are ready to look at systems

When you are ready to look at systems

What do you want to achieve?

1. More money/savings/ROI2. Better competitiveness3. Remote working4. Workflow benefits5. Better decision support6. Easier reporting7. Better information about

patients8. Improved quality of care

1. More money/savings/ROI2. Better competitiveness3. Remote working4. Workflow benefits5. Better decision support6. Easier reporting7. Better information about

patients8. Improved quality of care

1. More money/savings/ROI2. Better competitiveness3. Remote working4. Workflow benefits5. Better decision support6. Easier reporting7. Better information about patients8. Improved quality of care


Savings from Transcription

Patient Information

Capture

System Efficiency

Better Coding(not guaranteed)

Back-end Speech

Recognition

Front-end Speech

Recognition

Speech Recognition

• Automated coding

• Higher revenues from ‘lost’ charges and better coding

• Success varies

What Do You Want To Achieve?



Connectivity with Medical Community

Patient satisfaction

• Referrals• Reports• Labs• Hospital Communication• CCR

• Referrals• Reports• Labs• Hospital Communication• CCR

• Communication by email• Refills• Trust• Efficiency/convenience• Less waiting time• Technology attraction• Computer-generated patient

education• Guidance to websites• Web portals

• Communication by email• Refills• Trust• Efficiency/convenience• Less waiting time• Technology attraction• Computer-generated patient

education• Guidance to websites• Web portals




Remote Computing and Remote Documentation

• Working at home or anywhere

• Arranging your time accordingly




Workflow Benefits

• No waiting or searching for charts (for example, think of phone calls)

• Easier refills• Easier results management • Signatures• Immediate availability of patient data• Point-of-care documentation• Better time management




Computer and Internet Support for Decision Making

• Formularies• Diagnostic information• Information about medications• Other decision support info




• Query system by condition or medication

• Follow-up and reminders

• Standard reports

• Ad hoc and other reports

ReportsReports




• Receive patient information electronically

• Integrate and create CCR

• All insurance information

• Health status from other providers

Patient InformationPatient Information




• Health maintenance

• Disease monitoring

• Practice guidelines

• Patient education

• Lab tables/interfaces

• Data!!!

Improved Quality of CareImproved Quality of Care


How Can You Use EMRs for Quality Improvement?

• Templates with guideline prompts• Flow sheets, tables, summaries, etc. as decision

aids• Internal messaging and flags for coordination,

self-reminders, goal prompts• Personalized results letters or handouts for

patient education• Lab interface for results reporting• Advance scheduling for followup• Queries to identify patients needing specific care

leading to flags or outreach

How Can You Use EMRs for Quality Improvement?

• Develop effective team communication• Measure for improvement and

accountability• Incorporate performance and outcome data• Coordinate care and services across settings

What Should You Do?

• Educate yourself and others on EMRs– Conferences, web, colleagues, experts, etc.

• Prioritize goals and problems to solve– Narrow potential vendors: Determine• Cost• Features and functions• Usability

• Set-up vendor demos– Include physicians, staff–Develop scenarios– Site visits to similar practices

How Can You Compare EMRs?

• Practice size designed for, installed in?• IHN/hospital linked?• ASP-based?• Is system designed for and installed in

endocrinology practices?• Costs?• Functionalities?• Usability?

Comparing Costs• What else?– Interfaces and conversion

costs including mapping data fields

– License fees• One-time or annual

– Implementation– Training• Travel costs

– Support and upgrades– Backup: where and when– Other?

• What isn’t included?

• What does pricing include?– Hardware

• Data center only• Peripherals

– Software– Templates– CPT codes– E-prescribing– CCR integration– PHR integration

• What recurring costs?– Software/hardware

maintenance– Upfront or annual

license fees

Comparing Functionalities

Functionalities• Certification?• Continuity of Care Record or Document

(CCR/CCD) capability?• Other criteria…

Functionalities:Information Capture

• What modes of information capture does it offer?– Transcription– Speech recognition: front-end, back-end– Keyboard entry– Digital pen and paper– Handwriting recognition– Point and click– Pull-down menus– Templates, custom or standard– Home monitoring devices– Data entry by patient– Direct from mobile devices (mDevices)– HYBRIDS

Integration Functionalities

• Integration with – Practice management system – ePrescribing – Labs – Payers– Other?

Payer-related Functionalities

• Real-time eligibility determination?– With which payers?

• Real-time charge capture?– With which payers?

Interoperability Functionalities

• Is system interoperable with – Local hospital systems?– Personal health records?– Patient portals?– Patient data entry systems? – Other?

Comparing Usability

Usability• Demonstrations essential – How does one navigate in the system

• Easy• Intuitiveness• Suitable to your preferences/style

– How long does it take to do the same documentation in the EMR vs without the EMR

– How easy is it to query internal data or data from the system or other systems with which it is integrated

• Follow up standard demos with hands-on try-outs

???? to Ask

• Is version demonstrated the one you would be purchasing?

• Downtime?• Interoperability?– With what and how?

• Interfaces– What data fields are

included?• E-prescribing– Definition?– Transaction cost?

• Reports– Required?– Custom?

???? to Ask

• Hardware/software needs– ASP?– Hard-wired, wireless,

both?– Devices

• Data submission– What/how, e.g., data to

payers?– Pay for performance

data?

• Scanning– Speed? – Double-sided?– Quality

• Implementation time– Definition? – Does it include

installation, training, loading your data?

– What else?

Contract Considerations

• Exercise due diligence • Consult IT contract attorney• Establish payment milestones– Do not pay in full upfront

• Address response time– How do they prioritize?

• What about mergers?• Rights to your data– Escrow clause for source code

Implementation

• Different implementation paths for different practice sizes and specialties

• Realistic timeframes• Staff involvement• Workflow changes• Data conversion: scanning, CCR• Support and maintenance• Backups and recovery

Implementation• Plan and test, plan and test• Policies & procedures

– Privacy, confidentiality, security– Medicolegal requirements– Backups and disaster recovery

• Support and maintenance• Modular or “Big Bang”

– Have flexible timetables

• Appoint a project manager• Assign responsibilities• Modify schedules• Start immediately following training• Implementation never ends

All EMRs Are Not Equal• Price range is enormous–$1000 to $50,000+/physician

• No best of breed• Features vary • Not easy to change• Not just system but also workflow

makes difference between failure and success

Remember!

• EMRs differ for each application• Different needs, benefits, and

implementation paths for different domains/practices/individuals

• Sharing all information is not the goal• Ask questions! Don’t assume!

Remember!

• Making paper documents electronic does not achieve potential of EMRs

• Not easy• Spend resources to find out• Develop a strategy • Get buy-in• Not just EMRs, also computer-guided,

computer-supported healthcare

ePrescribing Systems

• Standalone ePrescribing or integrated within Ambulatory EMR?

• Both addressed by CCHIT (certification body)

Time Line for Certifying Standalone ePrescribing Systems

• Public comment periods (ended in April)• Publish final 09 Criteria, roadmap, and test

scripts: mid-May • Certification Begins: July 1

Certification: Capabilities for Qualifying ePrescribing Systems

Same for standalone and ambulatory EMRGenerate a medication listSelect medicationsPrint prescriptionsTransmit prescriptions electronicallyConduct safety checks

• Drug information, Inappropriate dose, Inappropriate route. Drug-to-drug interaction, Allergy concerns, Warnings/cautions

Provide information on lower cost alternativesProvide information on formulary or tiered formulary

medications, patient eligibility, and authorization requirements received electronically from patient’s drug plan

Comply with Part D standards for interoperability

2009 Unique Characteristics of Standalone vs Ambulatory EMR

• Focus on core ePrescribing of medications (vs. EHR)

• Problem list management proposed for future years

• Technical criteria geared to align with scope and architecture of ePrescribing standalone solutions

• Criteria included to provide following in an exportable format for migration to other systems– medication list– allergy list– prescription history data

ePrescribing – draft standalone certification criteria

• Identify and maintain a patient record

• Manage patient demographics

• Manage medication list• Manage allergy,

intolerance and adverse reaction list

• Order medications• Eligibility and formulary• Manage medication

orders• Support for drug

interaction and error checking

• Provider demographics• eRx interoperability• Concurrent use• Access control• Audit• Authentication• Data retention,

availability, and destruction

• Technical services• Backup/recovery

Standalone ePrescribing or Integrated within Ambulatory EMR?

• Your choice• Assess what makes sense for your practice• Consider the timeline• Interoperability essential

THANK YOU!

Electronic Medical Records (EMRs) and e prescribing Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical...

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